42 USC 1395cc-5 - Independence at home medical practice demonstration program

U.S Code last checked for updates: May 02, 2024

§ 1395cc–5.

Independence at home medical practice demonstration program

(a)

Establishment

(1)

In general

(2)

Requirement

The demonstration program shall test whether a model described in paragraph (1), which is accountable for providing comprehensive, coordinated, continuous, and accessible care to high-need populations at home and coordinating health care across all treatment settings, results in—

(A)

reducing preventable hospitalizations;

(B)

preventing hospital readmissions;

(C)

reducing emergency room visits;

(D)

improving health outcomes commensurate with the beneficiaries’ stage of chronic illness;

(E)

improving the efficiency of care, such as by reducing duplicative diagnostic and laboratory tests;

(F)

reducing the cost of health care services covered under this subchapter; and

(G)

achieving beneficiary and family caregiver satisfaction.

(b)

Independence at home medical practice

(1)

Independence at home medical practice defined

In this section:

(A)

In general

The term “independence at home medical practice” means a legal entity that—

(i)

is comprised of an individual physician or nurse practitioner or group of physicians and nurse practitioners that provides care as part of a team that includes physicians, nurses, physician assistants, pharmacists, and other health and social services staff as appropriate who have experience providing home-based primary care to applicable beneficiaries, make in-home visits, and are available 24 hours per day, 7 days per week to carry out plans of care that are tailored to the individual beneficiary’s chronic conditions and designed to achieve the results in subsection (a);

(ii)

is organized at least in part for the purpose of providing physicians’ services;

(iii)

has documented experience in providing home-based primary care services to high-cost chronically ill beneficiaries, as determined appropriate by the Secretary;

(iv)

furnishes services to at least 200 applicable beneficiaries (as defined in subsection (d)) during each year of the demonstration program;

(v)

has entered into an agreement with the Secretary;

(vi)

uses electronic health information systems, remote monitoring, and mobile diagnostic technology; and

(vii)

meets such other criteria as the Secretary determines to be appropriate to participate in the demonstration program.

The entity shall report on quality measures (in such form, manner, and frequency as specified by the Secretary, which may be for the group, for providers of services and suppliers, or both) and report to the Secretary (in a form, manner, and frequency as specified by the Secretary) such data as the Secretary determines appropriate to monitor and evaluate the demonstration program.

(B)

Physician

(2)

Participation of nurse practitioners and physician assistants

Nothing in this section shall be construed to prevent a nurse practitioner or physician assistant from participating in, or leading, a home-based primary care team as part of an independence at home medical practice if—

(A)

all the requirements of this section are met;

(B)

the nurse practitioner or physician assistant, as the case may be, is acting consistent with State law; and

(C)

the nurse practitioner or physician assistant has the medical training or experience to fulfill the nurse practitioner or physician assistant role described in paragraph (1)(A)(i).

(3)

Inclusion of providers and practitioners

(4)

Quality and performance standards

(c)

Payment methodology

(1)

Establishment of target spending level

(2)

Incentive payments

(d)

Applicable beneficiaries

(1)

Definition

In this section, the term “applicable beneficiary” means, with respect to a qualifying independence at home medical practice, an individual who the practice has determined—

(A)

is entitled to benefits under part A and enrolled for benefits under part B;

(B)

is not enrolled in a Medicare Advantage plan under part C or a PACE program under section 1395eee of this title;

(C)

has 2 or more chronic illnesses, such as congestive heart failure, diabetes, other dementias designated by the Secretary, chronic obstructive pulmonary disease, ischemic heart disease, stroke, Alzheimer’s Disease and neurodegenerative diseases, and other diseases and conditions designated by the Secretary which result in high costs under this subchapter;

(D)

within the past 12 months has had a nonelective hospital admission;

(E)

within the past 12 months has received acute or subacute rehabilitation services;

(F)

has 2 or more functional dependencies requiring the assistance of another person (such as bathing, dressing, toileting, walking, or feeding); and

(G)

meets such other criteria as the Secretary determines appropriate.

(2)

Patient election to participate

(3)

Beneficiary access to services

(e)

Implementation

(1)

Starting date

(2)

No physician duplication in demonstration participation

(3)

No beneficiary duplication in demonstration participation

(4)

Preference

In approving an independence at home medical practice, the Secretary shall give preference to practices that are—

(A)

located in high-cost areas of the country;

(B)

have experience in furnishing health care services to applicable beneficiaries in the home; and

(C)

use electronic medical records, health information technology, and individualized plans of care.

(5)

Limitation on number of practices

(6)

Waiver

(7)

Administration

(f)

Evaluation and monitoring

(1)

In general

(2)

Monitoring applicable beneficiaries

(g)

Reports to Congress

(h)

Funding

(i)

Termination

(1)

Mandatory termination

The Secretary shall terminate an agreement with an independence at home medical practice if—

(A)

the Secretary estimates or determines that such practice did not achieve savings for the third of 3 consecutive years under the demonstration program; or

(B)

such practice fails to meet quality standards during any year of the demonstration program.

(2)

Permissive termination

(Aug. 14, 1935, ch. 531, title XVIII, § 1866E, formerly § 1866D, as added and renumbered § 1866E, Pub. L. 111–148, title III, § 3024, title X, § 10308(b)(2), Mar. 23, 2010, 124 Stat. 404, 942; amended Pub. L. 114–39, § 2, July 30, 2015, 129 Stat. 440; Pub. L. 115–123, div. E, title III, § 50301(a),

cite as: 42 USC 1395cc-5